Prearrangement Form

A. Personal Information:

(If You are prearranging for another person, also Complete "B.")

Surname      Given Names	Sex Male Female
Address                City	Prov./State Postal Code	Home Phone   -    WorkPhone   -
CareCard Number	BC Resident Yes  No	Aboriginal Status Yes No               Registration#
Date of Birth (MM/DD/YY)	Age
Birth Place: City	Prov./State	Country
Status Never Married   Married  Separated Widowed Common Law Other

Spouse's Surname / Maiden Name	Spouse's Given Name
Kind Of Work Kind Of Business Industry	Years
Family Doctor's Name	Doctor's Phone Number   -
Surname and Given names of Father	Birthplace- City or Place, Province/ State or Country
Maiden name and Given names of Mother	Birthplace- City or Place, Province/ State or Country

B. If Prearranging For Another Person: (Your Information)

Name of Informant	Your Relationship
Street Address	Home Phone   -
	Work Phone   -
City	Province/State	Postal Code

C. Military Record:

Branch Of Service	Serial Number
Date Enlisted Month/Day/Year	Rank at Discharge
Date Discharged Month/Day/Year	Discharge on File at
Copy Of Discharge Papers     Yes No
Name Of Wars

D. Funeral Service Request

Type Of Disposition	Burial Cremation
Type Of Service	Conventional Service  in Chapel      with Burial  Or Cremation (Body Present)
	Conventional Service in Other Location      followed by  Burial or cremation (Body Present)
	Memorial Service in Our Chapel
	Memorial Service in Other Location      (With  staff in Attendance)
	Memorial Service in Other Location      (without   Staff in Attendance)
	Immediate Cremation
	Immediate Cremation with Viewing
	Immediate Cremation with Graveside
	Graveside Service
Location	Burquitlam Funeral Home Other
Seating	Family Seating at Burquitlam Funeral Home (6 people per row)  Rows    Receiving Line
Officiating	Clergy                    Religion
Viewing	Yes No Prefer Not, but at Family Discretion
Evening Prayers	Yes No
Memorial Package	Register: Yes No  Memorial Cards: To Be Printed On Cards:                  Picture of Person Poem Biblical Verse No Cards Required Quantity Required
Flowers For Ceremony
Music	Pre-recorded           Tape CD	Organist Soloist Choir     BagPipes
	1. 2. 3. 4.
Casket	Description:                           Open Closed If selected open Before During After
Urn	Description:                                                                       Present at Service Yes No
Preparation:	Preservation, Dressing, Cosmetic Care: Yes No Embalming Yes No
Clothing Instructions:
Jewellery:
Glasses:
Casket Bearers (6) (Leave Blank If Funeral Staff To Perform)    1.  2.        3.  4.      5.  6.
Obituary	Sun Province Other                            Number of Days
Cemetery Name                                                                                                                                                               Address                                                 City                                                                                                                          Province/State                                                                                                                                             Property Description                                                                                                                  Phone                                                                                                     -
Reception	Fireside Room at BFH   Other Location
Catering	Funeral home to Arrange Family to Arrange
Limo	Funeral Home to Arrange Family to Arrange None Required

E. Memberships /Affiliations

F. Other Instructions

G. Memorials/ Donations to Charity

H. Emergency Notification Service Card Information

Medical Problems/ Allergies
Medications Taken Regularly
Blood Type Type A Type B Type O Type AB Positive/Negative Positive Negative
Insurance Company	Phone   -
Doctor's Name	Phone   -
First Person To Notify	Phone   -
Religion
Do You Have a Will  Yes No
Are You an Organ Donor Yes No

Please Select One or More Of The Following:

 Send Information about Preplanning 

 Send Information about Prefunding  

 Contact Me to set up appointment